Essentials Hospital. Your hospital cover. What s restricted. What s excluded. What s not covered. What s covered. Product Guide

Transcription

1 Essentials Hospital Product Guide Effective from 1 December 2017 Your hospital cover Excess Essentials Hospital has a $200 per adult excess. The excess applies once per adult per financial year on all same day and overnight admissions. Your hospital cover gives you For services listed under What s covered : Choice of doctor and hospital 100% of agreement hospital charges (subject to your excess and any other non-health related charges applied by the hospital, e.g. television), including: Shared or private room Theatre fees Intensive care, critical care and high dependency unit Most drugs supplied in hospital 100% of public hospital charges (subject to your excess) Up to 100% of doctors fees, for services covered, if your doctor chooses to use Access Gap Up to 100% for prostheses on the Australian Government Prostheses List Access to My Medical Expert provided by the Best Doctors global network of specialists. Treatment in a non-agreement private hospital will incur significant out-of-pocket expenses. What s covered Accidental injuries Removal of tonsils Removal of adenoids Removal of appendix Surgical tooth extraction (hospital fees only) Hernia repairs, excluding hiatus hernia Joint investigations (arthroscopies) and minor joint repairs Joint reconstructions Colonoscopies Gastroscopies 100% cover for ambulance services by state-appointed ambulance providers across Australia (Transport services by Patient Transport vehicles are not ambulance services and are not claimable). What s restricted Psychiatric treatment Rehabilitation Palliative care. Benefits for restricted treatment will cover the cost of a private patient in a shared room of a public hospital. If you are treated elsewhere, such as a private hospital, you will incur additional and significant out-of-pocket expenses. What s excluded All other hospital treatments. What s not covered Situations where you will not be covered include: Hospital services listed as an exclusion Treatment received while serving a waiting period Treatment provided at an emergency department of a hospital Treatment for which a Medicare benefit is not payable (apart from rehabilitation, psychiatric treatments and palliative care) Treatment not clinically necessary such as cosmetic surgery Treatment in doctors rooms or specialist tests as an outpatient. (To understand inpatient and outpatient treatment, visit defencehealth.com.au/going-to-hospital) Doctors fees in excess of the MBS fee, unless covered by Access Gap Pharmaceuticals provided on discharge or unrelated to the reason for hospitalisation High cost drugs that aren t covered under the PBS or hospital contract Personal items such as newspapers, toiletries or TV Accommodation in an aged care facility Services claimable from another source such as workers compensation or third party insurance Hospital stays beyond 35 days where further care is not agreed between the hospital and Defence Health (this will incur out-of-pocket expenses). This cover is not suitable for overseas visitors who do not have full Medicare entitlements. 1 of 63

2 Talk to us on H Things you need to know about hospital Making the most of your cover Where you re treated affects your benefits We have agreements with more than 500 hospitals in Australia. By choosing to be treated in an agreement private hospital, you can significantly reduce your expenses. If you choose a hospital that does not have an agreement with Defence Health, you may have significant out-of-pocket expenses. Our agreement hospital listing is one of the largest in Australia. Search the list at defencehealth.com.au/hospital Reduce your medical costs with Access Gap Your doctor, surgeon, anaesthetist, pathologist and radiologist will all charge for their services separately. With Defence Health cover and the Medicare benefit 100% of the Medicare Benefits Schedule (MBS) fee for in-hospital services is covered. But some doctors charge above the MBS fee and this can result in significant out-of-pocket medical costs. Defence Health can help reduce or eliminate these extra medical costs if your doctor agrees to use our Access Gap scheme. Always ask your doctor what they will charge and if they will participate in our Access Gap scheme to reduce or eliminate the medical costs. You can search for doctors who may participate in our Access Gap scheme at defencehealth.com.au/accessgap Hospital waiting periods When you join Defence Health or upgrade your existing cover, you may have a waiting period before you can claim benefits. The following waiting periods apply: 12 months for pre-existing conditions (excluding psychiatric, rehabilitation and palliative care) 2 months for psychiatric, rehabilitation and palliative care Going to hospital Make sure you call us or check the information on our website before you go in to hospital. We can help you to understand what is covered, costs, the difference between a public and private hospital, and what treatments classify as inpatient and outpatient. Visit defencehealth.com.au/going-to-hospital Pre-existing conditions A pre-existing condition is an illness, ailment or condition where signs or symptoms existed in the six months prior to you joining or upgrading to a higher level of cover; whether you or your doctor knew of them or not. Only a medical or other health professional appointed by Defence Health is authorised to determine whether you have a pre-existing condition. If you need treatment in the first 12 months of joining for a condition that could be pre-existing, we may ask your doctor to complete a medical report. This will help our appointed medical advisor to assess if your condition was pre-existing. You should talk to us before going into hospital. Accidental injury benefit Essentials Hospital provides you with a benefit for injuries you sustain in an accident that occurred after joining this cover. An accident means an unplanned or unforeseen event leading to bodily injuries caused solely and directly by external means and requiring urgent treatment from a registered practitioner. To be covered you must provide documented proof from your registered practitioner that you sought treatment within 72 hours of the accident. If treatment in hospital is needed as an admitted patient, you will need to be admitted within 180 days of the initial treatment. After this 180-day period, any hospital treatment will be paid as per the level of benefits on your cover (that is, some benefits may be excluded or restricted). 2 months for all other covered services Cover for an accident is immediate, including ambulance service, where it is not claimable from another source such as workers compensation or third party insurance. If you transfer from an equivalent level of cover with another health fund and have served your waiting periods, you won t have to serve a waiting period with us. If you upgrade your hospital cover in the future you will have to serve waiting periods on all currently excluded and restricted treatments, including a 12 month waiting period on pregnancy related treatments. 2 of 63

3 Premier Extras Product Guide Effective from 1 December 2017 Dental Dental network Get a minimum of 15% off the usual dental fee at our network dentists. Visit defencehealth.com.au/dental for locations. General and preventive dental Annual limit Unlimited Periodic oral exam (012) Up to $50.40 Removal of calculus (114) Up to $89.00 Bitewing x-ray (022) Up to $36.00 Adhesive filling to one surface of a rear tooth (531) Major dental Up to $ Annual limit $1100 per person Surgical tooth removal (323) Up to $ Root canal obturation (417) Up to $ Veneer indirect (556) Up to $ Full crown veneer indirect (615) Up to $ Endosseous implant (688) Up to $ Orthodontics Annual limit $1000 per person Orthodontic treatment Up to $1000 Unlike other funds there is no lifetime limit. You get $1000 every financial year while you are receiving treatment. Some dental items are limited in the number of times they can be claimed in a year. Some are not payable in combination with others. And some may not attract a benefit at all. View full dental schedule at defencehealth.com.au/dental-schedule Ambulance treatment Annual limit Unlimited 100% cover for ambulance services by state-appointed ambulance providers across Australia. This includes emergency services, non-emergency dispatch, mobile intensive care and air and sea ambulance services. Transport services by Patient Transport vehicles are not ambulance services and are not claimable. Optical Optical network partners Annual limit $300 per person Our optical network providers have extensive ranges of no-gap glasses. If selecting outside of the no-gap range, benefits are payable up to your annual limit. Visit specsavers.com.au or vsp-australia.com.au for locations. Specsavers VSP Vision Care Single vision glasses 2 pairs no-gap 1 pair no-gap Bi/Multifocal glasses 1 pair no-gap 1 pair no-gap Frames Discounted Discounted Contacts (in store) 10% off 15% off Benefits at non-network providers are limited: up to $100 for single vision lenses, up to $105 for ground single vision lenses, up to $115 for bi-focal lenses, up to $175 for multi-focal lenses, up to $125 for frames and up to $200 for contact lenses. A sight-correcting script must accompany the claim. The no-gap glasses deals are based on standard lens options. Other lens choices are likely to involve an out-of-pocket cost. For the two pairs no-gap glasses deal, the second pair must be from the same or lower priced range and must be for the same prescription. Alternative therapies Annual limit $400 per person Per consultation Up to $38 Where the provider is recognised by the Australian Regional Health Group the following alternative therapies are payable: acupuncture, homeopathy, aromatherapy, myotherapy, naturopathy, remedial massage, remedial therapy, Chinese herbal medicine and western herbal medicine. No benefit payable for any prescribed medications, herbal or dietary preparations. Health and wellbeing Annual limit $180 per person Benefits are available for approved health screening tests (bowel screening, kidney check, mole mapping, bone density tests, mammograms and specialist eye tests), approved quit smoking programs and nicotine replacement therapies. Benefits available to members who have Premier Extras cover in combination with hospital cover. Benefits will not be available for treatments claimable through Medicare or for medicines/ drugs subsidised by the Australian Government under the PBS. An itemised pharmacy receipt with the patient s name must be provided. View detail at defencehealth.com.au/wellbeing 31 of 46

4 Talk to us on Your extras cover continued Flexi-limits Annual limit $1500 per person Physiotherapy (including hydrotherapy) Subsequent consultation Up to $54 Pelvic floor treatment Up to $75 Lymphoedema treatment Up to $100 Group therapy sessions and classes Up to $25 Services relating to pelvic floor muscles must be performed by registered physiotherapists in Private Practice holding post graduate qualifications specialising in pelvic floor muscle training. Services relating to lymphoedema must be performed by registered physiotherapists in Private Practice registered as a Category 1 Practitioner with the Australasian Lymphology Association. Chiropractic/Osteopathy Subsequent consultation Up to $43 Chiropractic x-rays (max 2) Up to $60 Exercise physiology Subsequent consultation Up to $34 Group therapy Up to $17 Antenatal and postnatal services Antenatal course Up to $500 Antenatal consultations/classes Up to $50 Postnatal consultations/classes Up to $50 By a midwife or physiotherapist in private practice only. Treatment claimed through Medicare cannot be covered. Psychology Subsequent consultation Up to $110 Group therapy Up to $45 Couple/family therapy Up to $65 Treatment claimed through Medicare cannot be covered. Speech therapy Subsequent consultation Up to $65 Group therapy Up to $50 Occupational therapy Subsequent consultation Up to $60 Group therapy Up to $35 Podiatry/chiropody Subsequent consultation Up to $43 Audiology Subsequent consultation Up to $65 Eye therapy Subsequent consultation Up to $60 Dietitian Subsequent consultation Up to $45 Pharmacy and vaccinations Per prescription or vaccination Up to $120 The benefit is payable on non-pbs pharmaceuticals only and applies to the cost in excess of the current PBS amount. Laser refractive eye surgery Limit $1500 per person every 2 financial years Up to $1500 per person is payable for LASIK, PRK or SMILE eye surgery in a recognised day surgery centre. School accidents No waiting period Annual limit $800 per person Up to $800 per person in additional benefits for costs resulting from a school accident to your child. To cover the gaps after your extras benefits have been provided, excludes Medicare services. Medically prescribed devices and supports Annual limit $1500 per person 12 month waiting period per person Hearing aids* Up to $1500 PAP machine* for sleep apnoea Up to $1250 Blood glucose monitor* Up to $500 Foot orthotics Custom-made or fitted by specialist orthotic practitioner. Excludes over the counter orthotics Orthopaedic shoes Custom-made or fitted by specialist shoemaker Splints and braces Splints, knee/leg/spinal/lumbar/sacral/wrist/ ankle braces and surgical corsets Mobility aids* Up to $1000 Wheelchairs, crutches, walking frames, walking sticks, rolling walkers, seat riser cushions, reaches and adjustable canes Joint fluid replacement injections e.g. Synvisc, OsteoArtz, Hyalgan Non-cosmetic prostheses Up to $1250 Annual sub-limits apply: Wig following a medical condition up to $300 per person External breast prostheses following a mastectomy up to $300 per person Artificial eye up to $1250* per person Blood pressure monitor* TENS machine* Nebuliser* and spacer for breathing conditions Compression garments Up to $1500 per item for TGA approved garments that are purpose made for aiding burns management, post-surgical recovery, lymphoedema treatment and deep vein thrombosis prevention 2 month waiting period per person Non-sight correcting Irlen lenses Up to $100 EpiPen Up to $150 Appliance maintenance Up to $100 For the repair of hearing aids and foot orthoses or for the purchase of appliance accessories like PAP machine masks Rental of appliances Up to $200 Including oxygen cylinders, soft collars, toilet seat risers, shower chairs, Continuous Passive Movement machines or any other appliance listed above * Replacement or additional items are not claimable within 3 years of previous purchase EPAP is not covered under the PAP machine benefit. 42 of 46

5 Talk to us on E Things you need to know about extras Knowing your annual limits All of the goods or services claimable under extras cover have annual per person limits. Some devices and appliances may include policy maximums. Once the annual limit has been reached, no further benefits are payable in that year. Limits are re-set on 1 July each year. Benefit payments will resume for treatment received after the beginning of the next financial year. You can easily monitor your available limits on our website, defencehealth.com.au/members Claiming extras benefits Many health care providers (like dentists, optometrists and physiotherapists) can swipe your membership card on-the-spot through an electronic terminal. The benefit payable is automatically credited to them and you then settle any outstanding amount. A list of providers who offer on-the-spot claiming is available on our website, defencehealth.com.au/extrasprovider If your provider doesn t offer on-the-spot claiming you can claim using one of the following convenient options: The simplest process is to claim via your smartphone through our Mobile Claiming App For the fastest refund claim online through the secure area of our website, defencehealth.com.au/members Or download a claim form from our website, complete it and then: it with your receipts to claims@defencehealth.com.au Fax it and your receipts to Post it and your original accounts or receipts to us: Defence Health, PO Box 7518, Melbourne, Victoria, 3004 Please hold on to your receipts for 2 years. Claiming conditions The most common claiming conditions are: All services must be provided by an approved practitioner in private practice Claims must be lodged within 2 years of receiving the service Benefits are only payable on goods and services purchased in Australia. When purchasing online the supplier must be a registered Australian company Benefits are only payable where Medicare benefits are not payable Benefits are not payable when they can be claimed from another source such as workers compensation or third party insurance. We recognise all those extras providers who are registered with their professional body and in the case of approved alternative therapies, those recognised by the Australian Regional Health Group. Remedial Massage providers must also hold at least a Diploma of Remedial Massage to be recognised. If you are unsure whether a practitioner is registered with us, visit Find an Extras Provider on our website, defencehealth.com.au/extrasprovider, or just give us a call. Full claiming conditions are available on our website, defencehealth.com.au/claim Extras waiting periods When you join Defence Health or upgrade your existing cover, you may have a waiting period before you can claim benefits. The following waiting periods apply: 12 months for major dental and orthodontic treatment 12 months for laser refractive eye surgery 12 months for most devices, aids and appliances 2 months for all other services Cover for an accident is immediate, including ambulance service, where it is not claimable from another source such as workers compensation or third party insurance. Remember, if you transfer from an equivalent level of cover with another health fund and have served your waiting periods, you won t have to serve a waiting period with us. 53 of 64

6 Visit defencehealth.com.au Our commitment to you Our values Our purpose is to support you, the members of the ADF and wider Defence community to manage your personal and family health care. Trust We will earn your trust by consistently delivering a personal experience for your needs. We are as good as our word every time. Excellence Our people are proud to serve you. They will provide service and experience others won t, or can t. We actively seek ways to continuously improve our offer to you. Ownership We re part of the ADF family. We accept responsibility, act with initiative, and follow through. We won t let you down. Respect We are friendly people, here to help you make good choices. We listen with intent and offer clear explanations, to provide you with peace of mind and support. Community We re here for people, not profit. We are committed to making a positive difference to the health and wellbeing of the Defence community. We value your feedback Compliments or complaints can be made by phone on or to info@defencehealth.com.au If we are unable to satisfy you, you can contact the Commonwealth Ombudsman on or at phio.info@ombudsman.gov.au. The Ombudsman provides free information and assistance to resolve disputes. You can view more information at Your privacy is important to us Defence Health has a legal obligation to comply with the Commonwealth Privacy Act 1988 and the Australian Privacy Principles. The Defence Health privacy statement informs you about how your personal information will be collected, held, used and disclosed, how you may gain access and seek correction of that information, and how you may complain about possible breaches of privacy. A copy of the full Privacy Policy is available at defencehealth.com.au. We will always endeavour to collect your personal information directly from you, but in some circumstances, for instance where you are a dependant on the policy, we will collect your personal information from the policy holder. We will generally collect and use your information to approve your transactions/claims, to provide services you have requested and to inform you of products, benefits and services we think may be of interest to you. We may use or disclose your personal information for another purpose, but only if we have your prior consent, or we are required to do so to fulfil our obligations as a private health insurer, or for any other reasonably expected purpose related to the provision of your health benefits. For example, we may disclose your information to other service providers we have arrangements with or who provide services to us, or where otherwise permitted or required by law. Policy holders will have access to certain personal information about dependants on the policy. Policy holders have an obligation to make dependants aged 16 years and over aware that they may contact us if they do not wish us to share their personal information with the policy holder or others on the policy. If you do not provide the information requested or do not consent to us requesting it from third parties, we may be unable to provide our health benefit services to you. You can view our privacy policy on our website, defencehealth.com.au/privacy Code of conduct We are committed to the Private Health Insurance Code of Conduct. You can download a copy of the code at defencehealth.com.au Defence Health Fund Rules Your cover will be provided and benefits paid in accordance with the Fund Rules of Defence Health Limited. You can download a copy of the latest Fund Rules from defencehealth.com.au or call us and we ll send you one. This Product Guide is current as at 1 December 2017, and is subject to change. It should be read carefully and retained. Defence Health Limited ABN AFSL of 64